Creation of a theoretically rooted workbook to support implementers in the practice of knowledge translation

Background Few training opportunities or resources for non-expert implementers focus on the “practice” as opposed to the “science” of knowledge translation (KT). As a guide for novice implementers, we present an open-access, fillable workbook combining KT theories, models, and frameworks (TMFs) that are commonly used to support the implementation of evidence-based practices. We describe the process of creating and operationalizing our workbook. Methods Our team has supported more than 1000 KT projects and 300 teams globally to implement evidence-based interventions. Our stakeholders have consistently highlighted their need for guidance on how to operationalize various KT TMFs to support novice implementers in “practising” KT. In direct response to these requests, we created a pragmatic, fillable KT workbook. The workbook was designed by KT scientists and experts in the fields of adult education, graphic design, and usability and was piloted with novice implementers. It is rooted in an integrated KT approach and applies an intersectionality lens, which prompts implementers to consider user needs in the design of implementation efforts. Results The workbook is framed according to the knowledge-to-action model and operationalizes each stage of the model using appropriate theories or frameworks. This approach removes guesswork in selecting appropriate TMFs to support implementation efforts. Implementers are prompted to complete fillable worksheets that are informed by the Theoretical Domains Framework, the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, the Effective Practice and Organization of Care framework, Proctor’s operationalization framework, the Durlak and DuPre process indicators, and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. As they complete the worksheets, users are guided to apply theoretically rooted approaches in planning the implementation and evaluation of their evidence-based practice. Conclusions This workbook aims to support non-expert implementers to use KT TMFs to select and operationalize implementation strategies to facilitate the implementation of evidence-based practices. It provides an accessible option for novice implementers who wish to use KT methods to guide their work. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-023-00480-w.


Integrated knowledge translation
involves engaging with knowledge users to develop a partnership to identify the best ways to design, implement and evaluate the practice change, using the best evidence available. A knowledge user is an individual who is likely to be able to use research results to make informed decisions about health policies, programs and/or practices 3 . When doing IKT, researchers and knowledge users both shape the research process by determining the research questions; deciding on the methodology; collecting data; developing tools; interpreting findings; and disseminating and implementing the research results 4 .
Integrated KT can involve additional resources including time, personnel, and funds, therefore it is important to reflect on and understand why pursuing integrated KT is worthwhile.
On a system level, the rationale is that fully involving knowledge users in the research process will lead to more relevant and applicable knowledge and a greater capacity for and likelihood of implementation.
This integration of knowledge-user and researcher expertise should lead to more research-informed decisions, more effective and efficient health services, and better health outcomes.
Without the involvement of knowledge users, research teams may make oversights that will decrease the relevance, feasibility, and applicability of research.
Intersectionality is a way of looking at the world that recognizes that our experiences are shaped by a combination of social factors including our ethnicity, gender, age, among others (these are called intersecting categories) as shown in Figure 2. These experiences occur within and interact with a context of connected systems and structures of power (e.g., laws, media) that exist within layered and connected systems at the individual, organizational and national/ international levels 5 . Taking an intersectional approach involves being inclusive and considering the unique experiences of those on our teams and in our communities. More information on intersectionality can be found in the Intersectionality & Knowledge Translation (KT) Reflection Workbook. Once you've identified WHY your target audience may or may not change their practice, use tools to identify corresponding strategies on HOW to overcome barriers and leverage facilitators.

STEP 5: PLAN for evaluation and sustainability
a. Identify implementation quality and process measures to monitor processes of implementation.
b. Develop patient and system measures to determine success of your implementation efforts.
c. Develop a rigorous plan for sustainability. How might your place in society impact your work on this project?
Reflecting on your response to the question above, how do your intersecting categories impact your place in society?
What intersecting categories make up your identity? Step 1: WHAT is the evidence based practice Defining The WHAT The first step to implementation is to identify the "know-do" gap, otherwise known as "identifying the problem." To identify the problem, we want to follow these steps: • First, in partnership with your knowledge users, determine the what the priority gaps are.
• Once your knowledge users have identified their prioritized gap/problem, work collaboratively to identify the best available evidence to address this problem. We want to ensure that we have high quality evidence for WHAT we are implementing. Systematic reviews and meta-analyses are considered the strongest and highest quality of evidence 7 , and ideally, we should use results from these reviews to guide our implementation plans. Often, however, this level of evidence is not available, yet we have identified a problem or gap that needs to be addressed. In this case, we will want to use the highest quality evidence available, while being cautious as we implement. It is often better to start with smaller-scale implementation and evaluate the impact of your implementation on process and clinical outcomes, before scaling up, especially when high-quality evidence is not available. This highlights the importance of thinking about and planning for evaluation early on in the implementation process!
• The next step is to assess the "gap" between what the evidence suggests should happen, versus what is actually happening in practice. Often, we will need to collect data using quality indicators to define this gap.
For more about Defining the Gap, see these resources 8 : • Once you have completed these steps, you can craft your WHAT. The WHAT should be the SPECIFIC practices that you want to implement, to address the problem/practice gap and align with the evidence. WHAT is the evidence-based practice you will use to address this gap?
2. Identify the overall goal of the implementation project.

Intersectional considerations for integrated KT:
Who decides which evidence-to-practice gaps are prioritized? WHO needs to change in order for the evidence based practice to be implemented?
1. Identify WHO needs to change their practice to align with the evidence-based practice.
2. Identify WHO will benefit from the change in practice.
e.g., For the MOVE program, providers will need to change their practice to align with the evidence. They will need to assess mobility within 24 hours of admittance; mobilize patients 3 times per day; and use progressive use scaled mobilization tailored to the patients ability.
e.g., Patients will benefit from this change in practice. Additionally, the hospital and the system will save costs associated with longer hospital stays.

Defining The Who
Once we have defined our WHAT, we need to think about WHO will be involved. Specifically, WHO needs to do what, differently?
For instance, a physician might need to change their clinical practice to align with the evidence-based practices. But others involved in, or impacted by the implementation process could include: patients, their caregivers/families, members of the community, other health care providers, those in the organization who provide implementation support (e.g., IT, administration), and decision or policy makers.
For each group of "WHOs" we identify, we should consider the following questions: • What are their viewpoints? What stake do they have in this implementation process?
• Can they impact the implementation plan? How?
• Are they impacted by the implementation plan? How?
Use the spaces below to clearly describe WHO is involved in your implementation project. Implementation involves different stakeholders at different levels of the healthcare system. Each implementation project's stakeholder descriptions will look different depending on the details of the project.

WHO is on your implementation team?
You will also want to identify your core implementation team. The implementation team is a core group of individuals (typically ranging from 3 to 5 people) who are accountable for guiding implementation, sustainability, and scale-up of the program. The implementation group does not include advisory groups, committees or representatives providing periodic input 11 .
Factors to consider when forming the Implementation Team include: • Who will be on the team?
• What are their perspectives on how KT can be implemented?
• What points of view are missing?
• What does leadership buy-in look like for the project?
Remember to include diverse representation of relevant stakeholders on your implementation team. For example, you might want to include 2 patients, a clinician, implementation specialist, and a nurse manager so that your team has a broad view of important considerations for multiple stakeholders. You will also need to consider who has time and capacity to join the implementation team.

Intersectional considerations for integrated KT:
Think about the group expected to change their behaviour. What intersecting categories of group members can we reflect on? Who is on the implementation team?
Policy makers: mandate specific clinical and system practices that align with evidence-based recommendations.
Researchers/Scientists: design and execute studies with the goal of developing new clinical and system procedures or improving the application of those already available.
Healthcare provider: provides healthcare diagnoses and treatment services.
Patient/community members: receive healthcare based on the evidence-based recommendations.
1. Identify WHO is on the implementation team at your site (e.g., who will develop, support and monitor implementation at each of the sites). Provide a rationale for selecting these people for the implementation team.
2. Identify WHO supports implementation. Implementation can be supported by internal staff who are not directly on the implementation team, but provide support and buy-in (e.g., health system administrator/manager), and/or implementation or evaluation expertise.
3. Are there other stakeholders involved in your implementation project? What are the real and perceived power differences on the team?
e.g., The manager and provider hold the majority of decision making power and also are perceived to be the most powerful based on their overall status within the organization.
Reflect on whether everyone who could be on the team has been asked if and how they would like to be involved. Think about how different perspectives that represent a range of intersecting categories have been examined. Next, we must determine WHY an individual or organization is likely to change or not change their practice.
In order to support behavior change and strategically bring about the practice changes we want to see, we need to:

Identify individual and contextual barriers and facilitators to changing practice
2. Map these barriers and facilitators to theories and frameworks to better understand what strategies will be used to overcome barriers and leverage facilitators

How do you identify barriers and facilitators to change?
Identify barriers and facilitators to change at both the individual and contextual levels by: Step 3: WHY would someone change their practice (or not)

3
The methods used to identify barriers and facilitators will depend on available resources (e.g., funding). Once you have identified barriers and facilitators to change, categorize your findings using a framework, such as the Theoretical Domains Framework (TDF) 13 to identify individual barriers and facilitators.
There might also be contextual barriers and facilitators to change. For an in-depth analysis of context, use a framework such as the Consolidated Framework for Implementation Research 14 (see Appendix A) and link corresponding strategies using the ERIC tool 15 .
By working through the following sections, you will be able to strategically link barriers and facilitators to corresponding intervention strategies (i.e., this tool will bridge the WHY and HOW). Environmental context and resources (Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour. One's group membership (real or perceived) influences the specific benefits, privileges, disadvantages, and oppressions that they experience inside and outside the workplace.)

• Environmental restructuring • Enablement • Restriction
Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours. Social processes can be real or perceived. They can be sourced from individual level (e.g., a manager), group levels (e.g., a professional working group), or societal levels (e.g., internalized racism). Notice that each TDF domain row has the related interventions indicated by an x. These are the interventions that are likely to address barriers and facilitators associated with that TDF domain b. For each TDF domain you checked, count the number of "x"s under each intervention and enter this number in the last row of the table (i.e., in the Total selected row). This will help you prioritize the most relevant interventions that will address the barriers/facilitators you identified in the previous section. The interventions with the highest number are the ones you should most consider implementing for your project.
Keep in mind that often, an intervention can address multiple barriers, at the same time (e.g., use of an educational intervention to build knowledge, skills and optimism for the project).

Coercion Education Enablement Environmental restructuring
Incentivisation Modelling Persuasion Restriction Training Total selected: Step 4: HOW can we help people change their practice 4

After you have mapped barriers and facilitators, you will then prioritize the interventions most relevant to your identified and mapped individual barriers and facilitators. Follow the instructions below to do this.
Practicing Knowledge Translation Workbook | 21 After you have prioritized the interventions most relevant to your individual barriers and facilitators, you will use this information to select and use strategies to bring about the evidence based practice. The strategies are the more specific details of your intervention will look like. For instance, if we flagged the need to use an educational intervention, the strategies will give us more granular details on what an educational intervention could look like.
This systematic approach to selecting and using strategies ensures we are using the most evidence-based approach to bring about the desired behavior change. We always want our implementation plan to be informed by evidence rather than the ISLAGIATT principle, which is It Seemed Like A Good Idea At The Time. (Martin Eccles) Use the table below to select the most appropriate implementation strategies to operationalize the interventions you prioritized above.
1. Interventions are noted in the first column. Go through this column to find the interventions you prioritized in the previous step.
2. With your team, strategically consider which strategies related to the prioritized interventions would be most appropriate, feasible, and likely to address the related barriers/facilitators 16 . You don't have to select every strategy that corresponds to your prioritized interventions. Remember to focus only on the strategies that are most likely to address the barriers and facilitators your team identified, and that are feasible in your context. Provide clinicians with ongoing supervision focused on the ideal practice. Clinical supervisors who will supervise clinicians should also be trained in the ideal practice Provider 1. Now that you have selected implementation strategies that explicitly address barriers and facilitators to change, you can strategically plan how to operationalize these strategies to achieve the desired outcome. Operationalization provides the specific details of how you will implement the strategy. It is important to keep note of these details, so we can later assess why a strategy did, or did not, work. For instance, is it that our education strategy was not effective, or was it just not implemented appropriately? It is also very important to keep track of these details in the event that a strategy is successful. This will allow you to provide others with the 'recipe' you used to achieve success, which they can then tailor or adapt to their context.

Intervention function is: Coercion
Once again, we see how important it is for us to think about evaluation throughout the process of implementation! Evaluating these processes will allow us to unpack the "black box" of why outcomes were or were not observed.
Use the table below to outline the details of how you will operationalize each strategy 17 Name of strategy As we have highlighted in earlier sections, it is important to think about evaluation throughout the process of implementation.
Even though planning for evaluation and sustainability are presented in this workbook as the last steps, you need to plan for these as you are completing the preceding steps. As you complete the preceding steps to create your implementation plan, you can simultaneously think about how you will evaluate and sustain implementation and desired outcomes.
Let's start with planning to evaluate the process and outcomes of implementation. There are many evaluation frameworks you can use to guide your overall evaluation. We like to use the Medical Research Council Guidance framework to inform the overall evaluation plan 18 .

Process Evaluation: Implementation Quality
Evaluating the process of implementation will help to understand what went according to plan and what didn't. This information will not only help explain implementation outcomes, but also adds to the science of implementation and helps inform the efforts of others working toward successful implementation.
To plan for a process evaluation, you need to identify indicators that will measure implementation quality. In other words, you need metrics that will assess how well your strategies were delivered.
For each implementation strategy you identified and planned to operationalize in the preceding steps, consider if the following indicators would be relevant. Use the following questions to help you identify process evaluation indicators that will help you assess the overall quality of your implementation strategies 19 .

Outcomes Evaluation: Impact
In addition to identifying process evaluation indicators, you also need to identify outcome indicators that will measure the impact of the intervention. We use the REAIM Framework to inform our outcome indicators. (See appendix B: REAIM) 20 .
Use an evaluation framework to help you select outcome indicators appropriate for your project. Then, identify these indicators in the space below.

Consider how you will plan for sustainability
Like your evaluation plan, your sustainability plan should also be considered as you are developing your implementation plan. Far too often, groups forget to plan for sustainability until they get to the end of implementation. It is important to plan for sustainability upfront so that the resources and efforts put into successful implementation continue to be utilized effectively. Use the table below to outline your implementation strategies, who they target, and what indicators you will use to measure implementation quality.
Thinking about this definition of sustainability in relation to your project, complete the sustainability factors table below to identify potential factors that could help and/or hinder the sustainability of your program.

Systems factors
How could the environment outside of the setting where the program is implemented influence the sustainability of the program (e.g., political environment)? Sustainability is defined as 21 : After a defined period of time, a program or implementation strategies continue to be delivered; behavior change aligned with evidence-based practice is maintained; the implementation strategies and evidence-based practice may evolve or adapt, while continuing to produce benefits for individuals/systems.

A. Structural Characteristics
The social architecture, age, maturity, and size of an organization.

B. Networks & Communications
The nature, quality, and inclusivity of webs of social networks and the nature, quality, and access to formal and informal communications within an organization.

C. Inner Culture
Norms, values, power structures, and basic assumptions (e.g., heteronormativity) of a given organization.

D. Implementation Climate
The absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization.
• Tension for Change The degree to which stakeholders perceive the current situation as intolerable or needing change.

• Compatibility
The degree of tangible fit between individuals' intersecting social categories and the meaning and values attached to the intervention by involved individuals, how those align with individuals' own norms, values, ways of knowing, and perceived risks and needs, and how the intervention fits with existing workflows and systems.
• Relative Priority Individuals' shared perception of the importance of the implementation within the organization.

• Organizational Incentives & Rewards
Existence of and access to external incentives such as goal-sharing awards, performance reviews, promotions, and raises in salary, and less tangible incentives such as increased stature or respect.

• Goals and Feedback
The degree to which goals are clearly communicated, acted upon, and fed back to staff, and alignment of that feedback with goals.
• Learning Climate A climate in which: a) leaders, representative of diverse intersecting social factors, express their own shortcomings and need and respect for team members' assistance and input; b) team members, representative of diverse intersecting social factors, feel they are partners and that their perspective is encouraged, essential, heard, valued, and considered knowledgeable in the change process; c) individuals feel psychologically safe to try new methods; and d) there is sufficient time and space for reflective thinking and evaluation in multiple venues/means (e.g., written reflection, discussion).

E. Readiness for Implementation
Tangible and immediate indicators of organizational commitment to its decision to implement an intervention.
• Leadership Engagement Commitment, involvement, and accountability of leaders and managers with the implementation.

• Available Resources
The level of resources dedicated for implementation and on-going operations, including money, training, education, physical space, and time.

• Access to Knowledge & Information
Ease of access to digestible information, available in accessible formats across user groups, and knowledge about the intervention and how to incorporate it into work tasks, based on individual intersecting social factors.

A. Patient Needs & Resources
The extent to which diverse patient perspectives, values, needs, as well as barriers (e.g., historical distrust of medical systems) and facilitators (e.g., high socioeconomic status) to meet those needs are accurately known, aligned with, and prioritized by the organization.

B. Cosmopolitanism
The degree to which an organization is networked with other external organizations.

C. Peer Pressure
Mimetic or competitive pressure to implement an intervention; typically because most or other key peer or competing organizations have already implemented or are in a bid for a competitive edge.

D. External Policy & Incentives
A broad construct that includes external strategies to spread interventions, including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-forperformance, collaboratives, and public or benchmark reporting and that the creation and sustainment of these strategies addresses systems of power, inclusivity, and equity.

E. Outer Systems & Structures
The overlapping structures and systems of a given society, including systems of privilege and oppression (e.g., sexism, racism, ableism).

F. Outer Culture
The norms, values, and basic assumptions (e.g., heteronormativity) of a given society.

A. Knowledge & Beliefs about the Intervention & those receiving the intervention
Individuals' attitudes toward and value placed on the intervention as well as familiarity with and access to facts, truths, and principles related to the intervention and those receiving the intervention (e.g., patients, other health providers).

B. Self-efficacy
An individual's belief in their own capabilities (related to their intersecting social factors) to execute courses of action to achieve implementation goals.

C. Individual Stage of Change
Characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention.

D. Individual Identification with Organization
A broad construct related to how individuals perceive the organization, and their relationship and degree of commitment with that organization.

E. Other Personal Attributes
A broad construct to include the intersection of other personal traits and social factors such as tolerance of ambiguity, motivation, values, competence, learning style. These individual traits and social factors interact with each other and other domains including the outer and inner setting (e.g., one's values regarding educational achievement will be influenced by social systems, such as sexism and racism).

A. Planning
The degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance, and the quality of those schemes or methods.

B. Engaging
Attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities.
• Opinion Leaders Individuals in an organization who have formal or informal influence on the attitudes and beliefs of their colleagues with respect to implementing the intervention.
• Formally Appointed Internal Implementation Leaders Individuals from within the organization who have been formally appointed with responsibility for implementing an intervention as coordinator, project manager, team leader, or other similar role.
• Champions "Individuals who dedicate themselves to supporting, marketing, and 'driving through' an [implementation]" [101] (p. 182), overcoming indifference or resistance that the intervention may provoke in an organization.
• External Change Agents Individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction.

C. Executing
Carrying out the implementation according to plan.

D. Reflecting & Evaluating
Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience.
The SELECT tool can be used to map WHY to HOW Step 3. Identify Implementation Strategies